Spotlight on Nursing Research/Delirium Superimposed on Dementia

Photo by Joe Howell

An 80-year-old patient with dementia is admitted to a hospital with pneumonia, and soon after, starts acting disoriented. Is this behavior part of his dementia or is it something else? What should the bedside nurse do to help?

Lorraine Mion, Ph.D., M.S.N., VUSN’s Independence Foundation Professor of Nursing, and part of a team from Penn State University and Harvard, is trying to find the answers and interventions for this complex issue with a five-year, multi-site study funded by the National Institute of Nursing Research. Specifically, they are looking at delirium superimposed on dementia – a growing concern, considering half of all hospital admissions across the country are for patients ages 65 and older.

“Dementia patients have heart attacks just like non-dementia patients. They have broken bones. They have infections that require acute treatment. So these are people who are going to be hospitalized,” said Mion.

Dementia is a chronic, progressive condition that is more common with older age. Delirium is an acute condition that has a rapid onset and results from multiple insults to the body, such as dehydration, infection or a drug side effect. Put the different issues together and unfortunately, most physicians and nurses consider the entire behavior as dementia. So, health care providers often opt for a drug treatment, which can lead to further problems such as falls or worsened delirium.

“It’s a significant issue that occurs in up to 80 percent of patients in Intensive Care Units, 50 percent to 60 percent of patients on the general surgical floors, and 20 percent to 30 percent of patients on medical floors,” said Mion. “Delirium in older adults is associated with longer lengths of hospital stay, more hospital complications, increased likelihood of being discharged to a nursing home if they had been living independently at home and greater likelihood of dying.”

The study is focused on four interventions to improve detection and management of delirium in these most vulnerable patients. The first is a foundation of education, though investigators know that education alone is not enough. The second component uses the electronic health record as a computer decision support to guide nurses in identifying risk factors or causes of delirium and providing non-pharmacologic management protocols. The third intervention is the use of a unit-based champion, a staff nurse who is a recognized leader among his or her peers, who wants to develop his or her skills in managing the care of dementia-hospitalized patients. Unit-based champions in this study receive additional education and training, round on cases and have weekly meetings with the specialist intervention nurse. The fourth intervention is the use of feedback – both at the unit level and with individual nurses in a private setting separate from their supervisor.

In addition to the concentration on bedside nurses, the study will look at how effectively this approach improves the health of patients.

“We hope this study will lead to improving the ability of nurses to assess and detect delirium as well as to identify risk factors for delirium, just as nurses identify risk factors for falls and pressure ulcers,” said Mion. “If we could do the same for delirium, we could prevent it or lessen its severity.”

If successful, Mion is particularly interested in translating their findings quickly and effectively into the hospital setting. Studies show that it can take as many as 20 years for best practices in all health areas to become part of routine care.

An 80-year-old patient with dementia is admitted to a hospital with pneumonia, and soon after, starts acting disoriented. Is this behavior part of his dementia or is it something else? What should the bedside nurse do to help?

“We hope this study will lead to improving the ability of nurses to assess and detect delirium as well as to identify risk factors for delirium, just as nurses identify risk factors for falls and pressure ulcers,” said Mion. “If we could do the same for delirium, we could prevent it or lessen its severity.”If successful, Mion is particularly interested in translating their findings quickly and effectively into the hospital setting. Studies show that it can take as many as 20 years for best practices in all health areas to become part of routine care.